Dialectical Behavior Therapy (DBT)

Dialectical behavior therapy (DBT) is a comprehensive cognitive behavioral treatment. It aims to treat people who see little or no improvement with other therapy models. This treatment focuses on problem solving and acceptance-based strategies. It operates within a framework of dialectical methods. The term dialectical refers to the processes that bring opposite concepts together such as change and acceptance.

Certified practitioners of DBT offer acceptance and support to people in therapy. Many of the people they work with have conditions described as "difficult to treat." They work to develop techniques for achieving goals, improving well-being, and effecting lasting positive change.

DBT can be used in a variety of mental health settings. It incorporates the following five components:

Capability enhancement. DBT provides opportunities for the development of existing skills. In treatment, four basic skill sets are taught. These are emotion regulation, mindfulness, interpersonal effectiveness, and distress tolerance.

Generalization. DBT therapists use various techniques to encourage the transfer of learned skills across all settings. People in therapy may learn to apply what they have learned at home, at school, at work, and in the community. For example, a therapist might ask the person in treatment to talk with a partner about a conflict. The person may use emotion regulation skills before and after the discussion.

Motivational enhancement. DBT uses individualized behavioral treatment plans to reduce problematic behaviors that might negatively affect quality of life. For example, therapists might use self-monitoring tracking sheets so sessions can be adapted to address the most severe issues first.

Capability and motivational enhancement of therapists. Because DBT is often provided to people who experience chronic, severe, and intense mental health issues, therapists receive a great deal of supervision and support to prevent things like vicarious traumatization or burnout. For example, treatment-team meetings are held frequently to give therapists a space to provide and receive support, training, and clinical guidance.

Structuring of the environment. A goal of therapy is often to ensure positive, adaptive behaviors are reinforced across all environmental settings. For example, if someone participates in multiple treatment programs within one agency, the therapist might make sure each program was set up to reinforce all the positive skills and behaviors learned.

The standard form of DBT consists of individual therapy, skills training group, phone coaching, and a therapist consultation team. Those in standard DBT attend therapy and a skills training group weekly. The groups are designed to help those in treatment develop behavioral skills through group work and homework assignments. These assignments allow people to practice learned skills in day-to-day life. Phone coaching is also an important part of DBT. It helps people in treatment reach out to their therapist for support when a challenging situation comes up between sessions.

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The issues faced by many who participate in DBT can be complex and severe. Due to this, a consultation team is considered essential for DBT providers. The team is made up of group leaders and individual therapists. It can offer support, motivation, and therapy to the therapists working with difficult issues.

Development and History

DBT was developed by Marsha Linehan in the 1970s. She developed DBT through her work with two mental health populations: people with chronic thoughts of suicide and people diagnosed with borderline personality disorder. Linehan was intrigued by the building reputation of cognitive behavioral therapy (CBT). She decided to utilize standard CBT in her practice. Linehan and her colleagues experienced difficulties after conducting research relative to the effectiveness of CBT in her chosen population. They discovered three major problems with the application of standard CBT:

Participants experienced the change-focused interventions as invalidating. These feelings often resulted in withdrawal from therapy, aggression toward therapists, or a fluctuation of both extremes.

Participants and therapists recreated a pattern of reinforcement in which good work was stalled and avoidance and redirection was encouraged. When therapists pushed for change, participants reacted in anger. When therapists allowed a subject change, participants reacted with warmth and positive feedback. This loop seemed to trick both therapist and participant into thinking they were on the right track, when in retrospect, they were not.

Due to the intensity of crisis-related situations, therapists spent a good deal of time addressing safety concerns, such as suicidal thoughts or gestures, hostility and threats toward the therapist, or self-injurious behavior. Often, little time was left to teach coping skills or address behavioral functioning.

After analyzing these problems, Linehan devised several adaptations to CBT. These directly addressed the needs of the population. Acceptance-based techniques were included to ensure participants felt supported and validated before they were asked to focus on change. In addition, dialectics were incorporated to allow therapists and participants in treatment to focus on the synthesis of polar opposites, such as acceptance and change. This helped them to avoid becoming trapped in patterns of extreme position-taking.

These and other adaptations were added to the practice of CBT. In 1993, Linehan published the first official treatment manual, Cognitive Behavioral Treatment of Borderline Personality Disorder. Since then, the practice of DBT has grown in popularity. Over the last several decades, a great deal of research has supported the efficacy of DBT. This form of therapy is now practiced in dozens of countries around the world. It is also listed in SAMHSA's Registry of Evidence-Based Programs and Practices.

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DBT Theory

Three major theoretical frameworks combine to form the basis for DBT. These are a behavioral science biosocial model of the development of chronic mental health issues, the mindfulness practice of Zen Buddhism, and the philosophy of dialectics.

The biosocial theory attempts to explain how issues related to borderline personality develop. The theory posits that some people are born with a predisposition toward emotional vulnerability. Environments that lack solid structure and stability can intensify a person's negative emotional responses. They can also influence patterns of interaction that become destructive. These patterns can harm relationships and functioning across all settings. They may often result in suicidal behavior and/or a diagnosis of borderline personality.

DBT draws mindfulness techniques from Zen Buddhism to use here-and-now presence of mind. This may help people in therapy objectively and calmly assess situations. Mindfulness training allows people to take stock of their current experience, evaluate the facts, and focus on one thing at a time.

Dialectics are used to support both the therapist and person in treatment. They pull from both extremes of an issue. Therapists use dialectics to help people accept the parts of themselves they do not like. They also use dialectics to provide motivation and encouragement to address the change of those parts. Synthesizing polar opposites can reduce tension and help keep therapy moving forward.

Stages and Goals in DBT

This form of therapy is designed to systematically and comprehensively treat issues in order of severity. Because DBT was initially intended for people with suicidal tendencies and extreme emotional issues, treatment happens in stages. This ensures all concerns are eventually addressed. DBT involves the following four stages:

Findings from multiple studies reflect the efficacy of DBT, especially for the treatment of borderline personality issues, posttraumatic stress, self-harm, and suicidality.

Stage 1. The focus of this stage is stabilization. People in therapy may be dealing with things like suicidal thoughts, self-harm, or addiction. They often report feeling like they are at an all-time low point in their lives. Therapy is centered on safety and crisis intervention. The goal of this stage is to help people achieve some control over problematic behaviors.

Stage 2. In this stage, behaviors are more stable, but mental health issues may still be present. Emotional pain is typically brought to the surface. Traumatic experiences are safely explored. The goal of this stage is for people in treatment to experience their emotional pain instead of silencing or burying it.

Stage 3. This stage focuses on enhancing quality of life through maintenance of progress and reasonable goal-setting. The goal of this stage is to promote happiness and stability.

Stage 4. During this stage, therapists support people in advancing their lives to the next level. In therapy, people may improve upon learned skills or work toward spiritual fulfillment. The goal of this stage is to help people achieve and maintain an ongoing capacity for happiness and success.

How Effective Is DBT?

Findings from multiple studies reflect the efficacy of DBT. It may be especially effective in treating borderline personality issues, posttraumatic stress, self-harm, and suicidality.

A controlled trial conducted in an inpatient setting by Bohus et al. (2004) found people in therapy who received three months of DBT improved at a greater rate than those who received treatment as usual.

According to the SAMHSA National Registry of Evidence-based Programs and Practices, multiple controlled trials and independent studies found one year of DBT decreased the instances of self-harming behaviors at a greater rate than alternative treatments. One such study reported that participants who received DBT had only .55 incidents of self-injurious behavior over one month, compared to 9.33 incidents among those who received treatment as usual.

A study conducted by Linehan et al. (2006) suggests DBT may be effective in reducing suicide attempts. This study reported those who received DBT were half as likely to attempt suicide. They had less psychiatric hospitalizations and were less likely to drop out of treatment compared to those who received psychotherapy from professionals considered experts in treating suicide and self-harm.

Certification Requirements for DBT

Some mental health practitioners offering DBT are not certified by the Linehan Board of Certification. The DBT-LBC program is the only developer-approved treatment program in the United States. Other programs may not provide practitioners with the necessary training to provide DBT effectively. Treatment from a provider who is not appropriately qualified may simply be unsuccessful but may also cause harm.

DBT is a type of therapy currently in high demand. Many practitioners may wish to offer this therapy in their practice. It is important for all practitioners who wish to offer DBT to obtain certification through the DBT-LBC program. Linehan herself discusses the importance of this certification in a live presentation for Family Action Network.

Practitioners interested in becoming certified must apply to take an exam. The exam is based on Linehan's training manual and skills training manual. Those who pass are then required to submit first a treatment conceptualization for a person they wish to treat with DBT. After that, they must submit three videotapes of consecutive treatment sessions with that same individual. If this completed Work Product adheres to DBT standards, and the practitioner has demonstrated the ability to effectively provide DBT, the practitioner can obtain certification as an Individual Therapist in DBT.

Criticisms and Limitations of DBT

A significant body of research suggests DBT is an effective treatment for several mental health issues. But there are a few criticisms and limitations.

Much of the available research on the efficacy of DBT included small sample sizes and focused on a specific sector of the mental health population. Critics argue more research should be done to determine if DBT works well for those with varied or complex mental health concerns.

DBT uses a detailed manual and requires solid training to implement. In many of the research studies where DBT was found to be effective, the providers implementing the DBT treatment were doctoral-level students or higher. Most were trained by the developer, Marsha Linehan. This does not necessarily indicate a weakness in the model itself but underscores the intensive amount of training required to deliver the services as designed. Therefore, expanding the availability of comprehensive training could be useful for community mental health organizations.

Many of the DBT research trials lasted up to a year. Some included a post-treatment follow-up interview. However, it was not determined whether therapeutic gains lasted beyond the post-treatment follow up interviews. Due to the chronic nature of the conditions treated, the field could benefit from more research measuring treatment gains long after the administration of DBT.

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